International Scholarly Research Network

ISRN Otolaryngology
Volume 2012, Article ID 181202, 10 pages
doi:10.5402/2012/181202

Clinical Study
Results and Complications of 1104 Surgeries for
Velopharyngeal Insufficiency

Jenő Hirschberg
St. John’s Hospital, Division of Pediatric Otorhinolaryngology, 1125 Budapest, Diós árok 1-3, Hungary

Correspondence should be addressed to Jenő Hirschberg, hirschbergjeno@gmail.com

Received 12 December 2011; Accepted 18 January 2012

Academic Editors: S. L. Halum and M. P. Robb

Copyright © 2012 Jenő Hirschberg. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Velopharyngeal insufficiency (VPI) means that the velopharyngeal closure is inadequate or disturbed. VPI may be organic or
functional, congenital or acquired and is caused by structural alterations or paresis. The symptoms are primarily to be found in
speech (hypernasality), more rarely in swallowing and hearing. The management types are as follows: speech therapy, surgery,
speech bulb, and others. Surgery is indicated if the symptoms of VPI cannot be improved by speech therapy. Among the operative
methods, velopharyngoplasty constitutes the basis of the surgery. The pharyngeal flap was incorporated and survived in 98.1%
of the cases, hyperrhinophony disappeared or became minimal in 90% after surgery in our material (1104 cases). The speech
results seemed to be the same with superiorly or inferiorly based pharyngeal flap. The Furlow technique, push-back procedure,
the sphincteroplasty, and the augmentation were indicated by us if the VP gap was less than 7 mm; these methods may also be
used as secondary operation. We observed among 1104 various surgeries severe hemorrhage in 5 cases, aspiration in 2 cases,
significant nasal obstruction in 68 patients, OSAS in 5 cases; tracheotomy was necessary in 2 cases. Although the complication rate
is rare, it must always be considered that this is not a life-saving but a speech-correcting operation. A tailor-made superiorly based
pharyngeal flap is suggested today, possibly in the age of 5 years.

1. Introduction The resonance problem, the hypernasality is among these

Velopharyngeal insufficiency (VPI) means that for whatever
reason the performance of the velopharyngeal (VP) closure is
inadequate or disturbed. VPI may be organic or functional,
congenital or acquired and is caused by structural alterations
or paresis. The symptoms and signs of palatal dysfunction are
primarily to be found in speech, more rarely in swallowing
and hearing. These symptoms depend mainly on the extent
of the defect in the closure mechanism, and on the time and
manner of its development. If the VPI is consequence of a
connatal anomaly or of a perinatal lesion, the first symp-
toms manifest itself immediately after birth: difficulty or
unability of sucking, pharyngeal secret stagnation, vomiting
through the mouth and nose, frequent aspirations, attacks
of suffocation, repeated pneumonias, and cardiorespiratoire
decompensation. The speech disorders are as follows: delayed
speech development, hypernasality, nasal escape, articulation
disorders (mostly secondary), facial grimaces, and hyper-
functional voice disorders (possibly with vocal nodules).
the leading problem which is an acoustic sign, while the
nasal escape is an aerodynamic symptom. In the diagnosis,
first routine examinations should be carried out: careful
history, intraoral inspection, simple functional tests (Czer-
mak’s mirror test, Gutzmann’s A-I probe, phonendoscope
test), orientative hearing examination, judging of the child’s
behaviour and intelligibility, and quick teachability test. The
instrumental examinations serve for confirming or rejecting
the routine procedures; they may be used to define (1) the
VP port, its dynamics, the fact, the degree and the type
of VP dysfunction (X-ray methods, CT, MRI, endoscopy,
ultrasonics), (2) pathological airflow (aerodynamic proce-
dures), (3) speech and voice production (articulation tests,
speech intelligibility test, nasometry, acoustic analysis), (4)
tube and hearing impairment (audiometry, tympanometry,
stapedius reflex test, OAE, BERA), (5) etiological factors
(neurological, electrophysiological methods, EMG, biopsy),
(6) to judge the personality, intelligence, and stimulability of
the patient (IQ test, personality tests and other procedures).
2 ISRN Otolaryngology
Table 1: Diagnosis in 1104 cases of surgeries for VPI.
Overt cleft palate 702
Submucous cleft palate 136
Shortening of the palate, VCFS 121
Deep nasopharynx, anatomical disproportion 54
Occult submucous cleft 3 0.27
Velar hypoplasia 6 0.54
Paresis 79
Destruction 3 0.27
Table 2: Distribution of 1104 surgeries according to age.
<4 years
4–6.11 years
7–9.11 years
10–13.11 years
14–18 years
>18 years
In the perceptual evaluation, the use of a four-point rating
scale is proposed for the description of all attributes assessed.
The treatment of VPI depends on the etiology. Only when
it has been unequivocally determined that no pathological
process is in the background of VPI, is there justification,
scope, and indication for speech (logopedic), phoniatric,
or phonosurgical therapy. The following types of treatment
may be used: (1) speech therapy, (2) surgery, (3) speech
bulb, (4) other treatment (medicaments, electrotherapy). In
considering the indication for velopharyngeal surgeries, we
must always remember that they are not lifesaving but speech
correcting interventions and that surgical complications—
though not too often—may also develop. The purpose, the
subject of the present article is to evaluate the operative
results, and the complications, the sequelae of various
surgeries for VPI.
2. Material and Methods
The basis of the recent study is about 6000 various facial
cleft operations including 1104 velopharyngeal surgeries for
VPI performed during 1965–2002 at the pediatric otorhino-
laryngological departments of the Heim Pál and Madarász
Children’s Hospital, Budapest/Hungary.
63.6% of the surgical interventions for VPI were per-
formed as secondary surgery, after staphylorraphy, in cleft
palate patients, the rest underwent primary operation indi-
cated in other forms of VPI (Table 1). Table 2 demonstrates
the distribution of the patients according to age: most of
them were children aged between 4 and 7 years. The type of
the used surgical technique is detailed in Table 3.
The VP closure mechanism, the anatomy of the VP port,
the definition, incidence, classification, etiology, genetics,
symptomatology, diagnosis, treatment of VPI, and the surgi-
cal methods were summarized in my main report of the XXth
Congress of the International Association of Logopedics and
Phoniatrics, and in Hungarian books [1–3].
Table 3: Distribution of 1104 surgeries according to the used
technique.
63.6%
12.30 Inferiorly based pharyngeal flap 916
10.96 Superiorly based flap 148
4.90 Sphincteroplasty sec Orticochea 9
Augmentation (implantation with Teflon,
20
later with autologous fat)
7.16 Furlow plasty 11
Altogether 1104
53 The Cleft Palate Committee of IALP (presided over
641 at that time by the author) was regarded as the most
194
informative instrumental diagnostic procedure in diagnosing
VPI: the cine (video) fluoroscopy, the nasopharyngoscopy,
134
and the nasometry, supplemented in some cases with
60
electrophysiological methods [4]. This standpoint is accepted
22 since then in our studies.
The Cleft Palate Committee of IALP organized a congress
in Visegrád/Hungary about Cleft Palate and Velopharyngeal
Insufficiency, where the authors with several specialities
(phoniatrics, speech pathology, otorhinolaryngology, audi-
ology, maxillofacial, plastic and pediatric surgery, orthodon-
tics, radiology, pediatrics, and genetics) from all over the
world gave a broad survey about many various questions on
the topic [5].
A book about the diagnosis and therapy of hypernasality
in cases of velopharyngeal insufficiency with and without
palatal cleft was published by us in 2006 [6].
In order to define the functional result (speech improve-
ment) and the factors which influence the surgical effect in
an approximately objective way, we performed a statistical
analysis using X 2 test on a randomly selected group of 261
patients at least 3 years after surgery with respect to nasality,
articulation, and speech intelligibility. First, 3 experienced
speech therapists assessed the speech (articulation, nasality)
using a four-point rating scale [7], then we applied our
speech intelligibility test [8] considering the following fac-
tors: age of patient at the time of operation, his hearing and
his level of intelligence, VPI etiology, type of surgery, status
of the velopharyngeal area after surgery, and postoperative
speech therapy.
The surgical complications of our 1104 cases were
detected by oral inspection and—if necessary—by
nasopharyngoscopy, radiological methods, or the help
with repeated intubation.
In judging the operative results, the possible complica-
tions, and in indication of a velopharyngoplasty, nasometry
may help us. We have used the nasometry adapted to
Hungarian language [9] in 160 children to corroborate the
listener’s detection of hypernasality and in deciding of a
velopharyngeal surgery or reoperation in dubious cases.
To decide whether pharyngeal flap surgery has an adverse
effect on the growth process of the craniofacial complex (or
not), lateral X-ray cephalometry was performed in randomly
selected 53 unilateral cleft lip and palate (UCLP) patients
with pharyngeal flap surgery: six angular and four linear
ISRN Otolaryngology
values were measured on the cephalograms [10]. The control
group consisted of 38 UCLP patients without pharyngeal
flap surgery. The significance test of the average values was
done with the two-sample t test. The level of significance was
α = 5%.
We have used polysomnography [11] among 68 patients
still snoring 1 year after surgery for detecting possible
obstructive sleep apnea.
3. Results
3.1. Surgical Results. Surgical results may be judged from the
angle of anatomical healing and functional effect.
The anatomical results are good: the pharyngeal flap
built in and survived long lasting in 98.1% of the cases.
In 94.1% the adhering was complete, in 4% the healing
was partial with dehiscences, in 1.9% the flap detached. In
cases of augmentation, the implanted material (Teflon, later
autologous fat) had never dropped out or had been absorbed
and we do not have any observed migration of the implant
or significant infection.
Regarding the speech improvement, we have obtained the
following functional results: hyperrinophony disappeared or
became minimal in 90% and moderate in 10%; speech intel-
ligibility proved to be excellent or good in 74%, acceptable in
21% and poor in 5%. Articulation was excellent in 42% after
surgery, the rest of the patients (1–6 sounds defective) were
referred for further speech therapy.
The speech improvement depends—at a significance
level of α = 5%—on the age of the patient (in younger
children the results are better than in older children or
adults), his hearing and mental level, the etiology of VPI (in
cases of structural changes of the soft palate the functional
effect is more advantageous than in cases of paresis), and the
postoperative anatomical status. According to our survey, the
type of surgery (inferiorly versus superiorly based method)
and the duration of the postoperative logopedic treatment
did not influence the functional effect. The surgeon’s expe-
rience and the competence of the speech therapist are, of
course, important but not measurable factors.
3.2. Surgical Complications. In our patient material (1104
cases) surgical complications were rare.
We have observed complications or undesirable sequelae
after surgery as follows:
(i) death: 0 case,
(ii) serious postoperative bleeding: 5 cases,
(iii) transfusion necessary: 5 cases,
(iv) aspiration, tracheotomy: 2 cases,
(v) detachment of the flap: 21 cases,
(vi) nasal obstruction (snoring 1 year after surgery): 68
patients,
(vii) OSAS (verified by polysomnography): 5 patients,
(viii) widening of the lateral orificii beside the flap because
of significant nasal obstruction or OSAS: 11 cases,
3
(ix) maxillofacial development. In sagittal relation, the
maxilla and mandible became more retrognathic
in each patients after flap surgery (the anterior
facial height does not show any differences); but the
observed changes were not significant.
4. Discussion and Conclusions
Ever since Rosenthal [12] and then Sanvanero-Rosselli [13]
renewed Passavant’s [14] and Schönborn’s [15] old surgical
concept, the question of speech-improving operation has
become one of the central subjects of the practice and
literature concerned with CP surgery and VPI [16, 17]. Three
important questions should be considered: in which cases is
surgery indicated, at what age of the patient should surgical
intervention be performed, and what types of surgery or
procedures are available, of which the best result can be
expected with the minimum of risk and complications.
Creating the structural elements necessary for velopha-
ryngeal closure is the essential goal of surgical correction
of velopharyngeal insufficiency [18]. We recommend surgery
in those cases of organic VPI which imply a persistent
condition (i.e., where a progressive neurological process can
be precluded), where no results can be expected on the
basis of teachability tests or other data of examination or
have been achieved by means of speech therapy of 4–6
months. According to an extensive survey by Schneider and
Shprintzen [19], 80% of VPI patients receive speech therapy.
If this conservative treatment is unsuccessful, or it seems to
be hopeless from the outset, surgery should be indicated.
As a first step, however, neurological processes should be
excluded.
The velopharyngeal surgery is a speech-correcting oper-
ation, although sometimes it may improve also the faulty
swallowing and conductive hearing problem. Its aim is first
of all improving the phonation, the timbre of the voice.
Thus, this surgical intervention belongs (also) to the field of
phonosurgery [20, 21]. Phonosurgery is still an integrative
part of phoniatrics. The surgeon’s proper place to some
discipline is not decisive, it is important, however, that
he/she
(i) should well know not only the anatomy but also the
functions of the VP sphincter,
(ii) should perform such kind of operations regularly to
have enough experience, and
(iii) should ensure the contribution of the representa-
tives of all disciplines (otorhinolaryngology, speech
pathology, audiology, phoniatrics, neurology, oral
surgery, genetics, orthodontics, pediatrics) who may
take part in the diagnosis and care of patients with
VPI.
Most of these surgical interventions are performed
secondarily, after palatoplasty, in cleft patients. According
to a large survey, secondary VP surgery was performed
in 0–40% after various cleft palate operations in different
CP centers [6]. In our own material, speech-correcting
operation was necessary in 16.8% among 613 CP patients
4 ISRN Otolaryngology
after Langenbeck’s staplylorraphy [20]. Further pathologies
which may need palatopharyngeal surgery primarily or not
too often secondarily, are submucous cleft palate, occult
submucous cleft palate, congenital or acquired shortening of
the velum, various syndromes (velocardiofacial syndrome =
VCFS, Robin sequence), and paresis of the palate.
Correct judgement and comparison of the functional
results, the speech improvement is difficult: patients concern-
ing age are not unique in the different studies. The indication
is inhomogene, criteria and methods of evaluation are
different, the data of the subjective and objective evaluation
do not correlate.
As the number of the successful surgeries is given in
various publications to be between 67% and 97%, in general
the functional results are published to be about 80–90%.
There are several factors which may influence the
functional results according to many publications: age of the
patient at the time of operation, etiology of the VPI, hearing,
intelligence of the patient, preoperative correct diagnosis,
type of operation, and mobility of the lateral pharyngeal
wall. These data are supported and confirmed by our own
experiences.
Most authors [22–24] agree that the results are better
in younger than in older children or adults. Stoll et al.
[25] emphasize that the best results may be attained—
independent on the surgical method—if the patient is
operated on or before the age of 6 years. Our opinion is that
the ideal age for velopharyngoplasty is around 5 years of age:
the failure of speech therapy is revealed by this age, the child
is sufficiently co-operative in the days following operation
which is not always easy; moreover, if chosen, postoperative
speech therapy can also be commenced before the age of
schooling. This effort and proposal is reflected also by our
surgical statistics: most of the children operated on by us
because of VPI were in the age group of 4–6.11 years. Also,
the number of complications is smaller in young children
than in adults [26, 27]. Of course, the choice of the time of
surgery may be influenced by several factors: time of correct
and final diagnosis, general health of the child, attitude
and decision of the parents. Early diagnosis is essential: our
aim is, therefore, to detect supposed hypernasality due to
(occult) submucous cleft palate or latent VPI with the aid of
nasometry of the infant cry [28]. Not evident cases can easily
be overlooked by routine inspection, especially in infancy
with severe consequences later on, for example, repeated
adenoidectomy erroneously performed.
The intelligence level of the child has an unequivocal effect
on the tendency of the result [22, 29]. In our opinion, the
minimum IQ score should be over 50 [30, 31].
Hearing impairment before the operation may also affect
the possible functional result; major perceptive hypacusis
reduces the chances of improving speech.
To achieve a satisfactory effect with the vertical flaps, the
lateral pharyngeal wall must have a good movement (Figures
1(a) and 1(b)).
For receiving good surgical and functional results, proper
choice of an adequate operative method is essential.
Many great different kinds of surgical methods and
techniques were described and used over the past 100 years
for the surgical improvement of hyperrhinophony due to VPI
(Figures 2–7):
(i) push-back procedures,
(ii) pharyngoplasties which do not touch the velum,
(iii) sphincteroplasty sec Orticochea,
(iv) velopharyngoplasties (flap surgery),
(v) levator-plasty,
(vi) Z-palatoplasty sec Furlow,
(vii) augmentation techniques,
(viii) modifications and combinations of the techniques.
In Figures 2–7, various surgical methods for VPI
(printing with permission of Median Verlag) are shown.
Undoubtedly, the velopharyngoplasties constitute the basis
of palatopharyngeal operations for VPI: the so-called flap
surgery is the most common among surgeries correcting
hypernasality. The insertion of the pharyngeal flap into the
velum can be done by different techniques; the two basic and
most frequent methods are the inferiorly and the superiorly
based version (Figures 2-3). Using the inferiorly based
version, we lengthen the palate with an apron flap suggested
by Herfert [32]. The question of which techniques is better
and more successful cannot be unequivocally decided. It is
a fact that more surgeons use the superiorly based method
today [18, 33, 34], although some authors did achieve better
functional results with the inferiorly based version [35].
According to our evaluation, the speech results are the same
in both forms [6], each type has, however, some advantages
and disadvantages (Table 4).
The so-called sphincteroplasty (Figure 4) is associated
with the name of Orticochea [48, 49], as he himself said:
“the sphincter has been discovered.” Orticochea made use
of the palatopharyngeus muscles and sutured them in an
inferiorly based pharyngeal flap, thus establishing the basis
for sphincter-pharyngoplasty. This method became more
and more popular in the last two decades and is particularly
indicated when there is good movement of the soft palate,
with poor movement of the lateral pharyngeal wall [50]. We
obtained good results applying the Orticochea technique as a
secondary operation after unsuccessful velopharyngoplasty:
we attached the posterior tonsillar pillars to the rest of
inferiorly based pharyngeal flap [1, 2].
The surgical technique published by Furlow [51] is an
intravelar palatoplasty (Figure 5). The so-called Z-plasty
means using two flaps of the velum lying opposite each other,
one from the oral, the other one from the nasal layer. Thus, a
muscular ring will be formed which lengthens the soft palate
without using the tissues of the hard palate. This technique
is suggested if the lateral pharyngeal wall functions well and
the velopharyngeal gap is not larger than 7 mm.
In case of insufficiency, the VP port can be narrowed
by the forward bulging (augmentation) of the posterior
pharyngeal wall, too (Figure 6). Different kinds of material
can be implanted at the level of the second cervical vertebra,
between the submucosa and the superior constrictor muscle:
Silastic, Teflon, Proplast, and biological tissues as fascia, fat,
ISRN Otolaryngology 5

(a) (b)

Figure 1: Inferiorly based pharyngeal flap in rest (a) and during sound production (b). The lateral pharyngeal walls narrow and then close
the apertures beside the flap.

Figure 2: Inferiorly based pharyngeal flap. Figure 4: Orticochea method (sphincteroplasty).

Figure 5: Furlow technique.

Figure 3: Superiorly based pharyngeal flap.

cartilage. We first used Teflon, in the last ten years autologous

fat. Augmentation may be indicated:

(i) primarily, into the posterior pharyngeal wall, if the

VP gap is less than 7 mm during phonation and the
soft palate is mobil,
(ii) secondarily, after unsatifactory result of a
velopharyngoplasty. The correct localisation of
implantation should be decided in these cases with Figure 6: Augmentation.
the aid of oral inspection and nasopharyngoscopy.
6 ISRN Otolaryngology
Figure 7: Push-back procedure.
The purpose of the push-back procedures (Figure 7) is to
lengthen the secondary palate by means of mobilisation, that
is, the caudal placing of the soft palate. As a result, the VP
gap becomes smaller and improvement in speech is effected.
Suitable cases might include those with a short palate, with
adequate pharyngeal wall movement and a relatively small
defect. Because of the last circumstances and restriction and
because of the possible risk of maxillary growth impairment
due to denudation of large areas of bone, this method is used
today only in a limited number of application.
The pharyngoplasties [52], and the so-called levator
plasty [53] may be used in cases of slight VPI.
In summarizing the different velopharyngeal operative
methods, it may be said that a tailored, superiorly based
pharyngeal flap is suggested first of all today. However, it is
also correct to say that the best method is the one where
a skilled surgeon has the best experience and had already
achieved the best results.
The complication rate and the undesirable sequelae are
not frequent. It must be always considered, however, that
it is not about a life saving but about a speech correcting
operation.
Surgical complications happen mostly at flap surgeries
which need larger incision and mobilisation. Consequences
of the augmentation technique are minimal [54]: infection,
hematoma, throwing out, or migration of the implant may
be counted to the latter. We have not experienced any side
effects applying augmentation.
Complications of pharyngeal flap surgery are also rare
[55], other authors [43] stress, nevertheless, that this tech-
nique is one of the more dangerous pediatric procedures due
to the potential for airway obstruction and patient death.
Although airway compromise in patients who undergo
pharyngeal flap palatoplasty can be a potentially fatal com-
plication [37], I agree with Sullivan et al. [46] that this type of
operation is highly successful with about 80–90% functional
result and a low risk of complication. The complications are
connected with the chosen anesthesia or with the surgery
itself and can be classified as mild, transitory, or permanent
and serious side effects.
There are some unpleasant but not serious problems
postoperatively which occur in almost every patients;
they are, however, transitory and disappear in a few days:
significant pain and restriction of movement of the neck,
and low fever.
Nasal obstruction, snoring, and rhinophonia clausa are
also regular after surgery, but these problems gradually
decrease and mostly stop as a result of the transversal
contraction of the flap in some weeks or 2-3 months.
Bronsted et al. [27] found hyponasality in 39% of 140 cases
postoperatively, but 5 years later persistent hyponasality was
revealed in only 9 patients.
Serious (or late) complications may be the following:
(i) complications in connection with the anesthesia,
(ii) infection,
(iii) hemorrhage,
(iv) aspiration, tracheotomy,
(v) death,
(vi) detachment of the flap,
(vii) prolonged nasal obstruction,
(viii) obstructive OSAS,
(ix) disorders in maxillofacial development,
(x) others, rare.
The two most serious complications are hemorrhage and
significant airway obstruction [6, 36].
The usual reason for major bleeding is that the arteria
pharyngea ascendens gets injured when a wide inferiorly
based pharyngeal flap is cut out, but the bleeding can
generally be stopped. The flap surgery requires peculiar
attention in patients with VCFS, as in these cases the carotid
arteries may be medialized [56]. More serious problems are
caused by the mostly diffuse bleeding in the postoperative
period because it can result in the loss of the flap and
become the source of grave conditions: transfusion, aspi-
ration, pneumonia, tracheotomy may be the consequences.
The number of serious hemorrhages is fortunately not too
high: we observed postoperative bleeding that necessitated
blood transfusion in 5 of our 1104 patients, four patients
required takedown of the pharyngeal flap and we were
compelled to tracheotomy in 2 cases because of significant
blood aspiration. According to the literature, postoperative
bleeding which claims reintubation, surgical revision or
transfusion is about 0.5–2% [27, 33, 57].
Detachment of the flap may also occur in patients without
postoperative bleeding. Insufficiency of the sutures manifests
itself generally on the 8–10th postoperative days. Its cause
cannot be always diagnosed. Undoubtedly, faulty surgical
result of flap surgery is more frequent in patients with a
very large VP gap, if the velum is cicatrized in operated
CP patients, and it happens more often in adults than in
young children presumably because of worse blood supply.
Reoperation is possible but not with the same method; for
secondary surgery, we use first of all the Orticochea technic
or augmentation. We have observed that after a faulty flap
surgery the speech does not worsen in every case, sometime
it even improves. Explanation for this may be that the
rest of the pharyngeal flap and—in case of inferiorly based
ISRN Otolaryngology 7

Table 4: Advantages and disadvantages of the superiorly and inferiorly based pharyngeal flap.

Superiorly based flap
Inferiorly based flap
Advantages Disadvantages
more physiological more nasal obstruction
postoperative bleeding may be stopped easier later correction is more difficult
larger VP gap can be bridged
later correction is easier difficult to stop postoperative hemorrhage
less nasal obstruction less physiological
function well visible during speech therapy

Table 5: Complications of surgery for velopharyngeal insufficiency in several publications.

Author(s),
Number of patients Diagnosis Mean age Type of operation Complications
publication time
bleeding: 18, reintub: 3,
Valniček et al. 1994
219 (1985–1992) VPI 9.6 years Sup.based flap airway obstruction: 20,
[36]
OSAS: 9, death: 1
airway obstruction: 7,
Pena et al. 2000 [37] 88 (1983–1997) VPI Flap palatoplasty OSAS: 1, apnea: 1, death: 1,
aspiration: 2
CP, VPI
Sie et al. 2001 [38] 48 6.5 years Furlow palatal fistula: 2
syndromes
Sup. and inf. based bleeding: 2, reintub.: 1,
Hofer et al. 2002 [39] 275 (10 years)
flap dehiscence of flap: 9
Nakamura et al. 2003
15 CP, VPI Intravelar veloplasty partial flap necrosis: 2
[40]
Morita et al. 2004
18 CP, VPI children Sup.bas.flap OSAS: 2, tracheot.:1
[41]
Chegar et al. 2007 bleeding: 3, transf: 1,
54 (1996–2003) VPI children Sup.bas.flap
[42] snoring: 4, OSAS: 0
infection: 1, bleeding: 3,
Cole et al. 2008 [43] 222 VPI 6.4 years Sup.phar. flap
OSAS: 5
Keuning et al. 2009
130 VPI Sup.bas.flap bleeding: 1, dehiscences: 3
[33]
Ysunza et al. 2009
29 (2000–2007) VCFS Flap: 20, Sphincter: 9 no complications
[44]
Leuchter et al. 2010 Augmentation, diff. hematoma: 1,
18 (2004–2007) mild VPI
[45] implants cervical pain: 1
Sullivan et al. 2010
104 (1981–2008) CP, VPI 8.6 years Sup.bas.flap OSAS: 2
[46]
Kilpatrick et al. 2010 fever: 2, bleeding: 1,
36 (2003–2009) CP,VCFS 8.1 years Sphincteroplasty
[47] allergy: 1, O2 therapy: 4

version—the velum lengthened with the apron flap narrow
the VP closure in some degree.
A serious airway obstruction with danger for suffocation
can happen in the early postoperative period by aspiration of
blood or—especially in retrognathic children—by retroposi-
tioning of the tongue [37, 58]. According to Willging [18],
the superiorly based pharyngeal flap minimize the potential
for obstructive complications associated with pharyngeal
flap.
Death is extremely rare but cannot be excluded. The
death, however, may have also general cause, it is not always
in direct connection with the surgery itself [37, 59]. We have
had no mortality among our 1104 operated patients.
Several authors give account of postoperative sleep apnea
(OSAS) which is a major complication of pharyngeal flap
surgery [41]. Ysunza et al. [60] found 15 OSAS with
polysomnography in 585 cases after (velo-) pharyngoplasty,
Valnicek et al. [36] 9 cases among 219 children. In our
1104 patient collective, we found 5 cases with postoperative
OSAS verified by polysomnography. If the nasal or airway
obstruction is permanent and significant and in patients with
OSAS, the widening of the lateral apertures beside the flap
may solve the problem. We performed this type of correction
in altogether 11 cases with success, with improvement of
the breathing. If this intervention is not enough, very rarely,
cutting through the flap may come up. Preoperative sleep
8 ISRN Otolaryngology
study with complete nasal obstruction with nasal tampons
could be useful for predicting the risk of upper airway
obstruction secondary to pharyngeal flap surgery [41]. We
suggest polysomnographic investigations before pharyngeal
flap surgery and also before palatoplasty in retrognathic
children to predict the probable postoperative breathing
problems. According to Chegar et al. [42], complications
related to obstructive sleep apnea have been significantly
reduced while maintaining excellent speech results by a
staged approach of removing tonsils and adenoids and by
creating a short, wide, superiorly based pharyngeal flap. In
our practice, we routinely perform adenoidectomy before
velopharyngoplasty and remove also the big tonsils for easy
cutting out of the inferiorly based pharyngeal flap. In the
latter case, in selected patients, some part of the tonsillar bed
may be used for receptive bed of the flap during surgery.
The surgical narrowing of the VP port may influence
the maxillofacial development, this does not result, however,
in a significant deformation. It was demonstrated by us on
the basis of cephalometric investigation in 53 patients [10].
The maxilla and the mandible become more retrognathic
in the sagittal relation and the vertical proportion of the
face increases after velopharyngeal surgery. The mandible
takes up a position more down- and backward. It may
be said that although pharyngeal flap surgery increases
the existing sagittal and vertical distortions in UCLP and
VPI patients, these do not reach a degree that would
justify the abandonment of the good functional effect of
veloparyngoplasty. Long and McNamara [61] also demon-
strate several areas of change in facial growth following flap
surgery, but this should not and does not negate its value
as a desirable rehabilitative procedure. According to our
study, the maxillofacial development is more propitious if
operation is performed before the age of 7.
Velopharyngoplasty produces no adverse effect on the
condition or function of the ear [62, 63]; sometimes the
number of serous otitis could be higher after surgery. In
patients with severe perceptive hearing loss, good functional
results cannot be expected, thus, in these cases surgery
should not be indicated.
Table 5 summarizes the complication’s rate in the mate-
rial of several authors.
In order to prevent or at least decrease the number of
complications, the following steps are important:
(i) thorough preoperative examination, early and sure
diagnosis,
(ii) consideration of contraindications, and the medial-
ized carotid arteries in cases of VCFS,
(iii) adequate narcosis,
(iv) correct operative technique,
(v) appropriate experience, practice and skill of the
surgeon,
(vi) appropriate postoperative care,
(vii) suitable diet and supervision.
5. Summary
Velopharyngeal insufficiency touches many various func-
tions, principally: deteriorates the speech. Among the speech
disorders, hypernasality is the leading symptom. If this
cannot be improved by speech therapy, surgery is indicated.
There are several operative methods, the pharyngeal flap
surgery is among them the most common procedure, a
valuable tool. 1104 velopharyngeal surgeries for VPI were
performed by the author during 1965–2002. The anatomical
results were good: the flap built in and survived long lasting
in 98.1% of the cases. In 94.1% the adhering was complete, in
4% the healing was partial with dehiscences, in 1.9% the flap
detached. Regarding the functional results, hyperrinophony
disappeared or became minimal in 90%, moderate in 10%;
speech intelligibility proved to be excellent or good in
74%, acceptable in 21%, and poor in 5%. Articulation was
excellent in 42% after surgery; the rest of the patients (1–6
sounds defective) needed further speech therapy. A tailor-
made superiorly based pharyngeal flap is suggested first
of all today, possibly in the age of 5 years. Although the
complication rate is rare, it must be always considered that
this is not a life-saving but a speech-correcting operation.
The two most frequent complications are postoperative
bleeding and airway obstruction. We observed among 1104
surgeries serious hemorrhage in 5 cases, aspiration in 2 cases,
transfusion was necessary in 5 cases, tracheotomy in 2 cases;
detachment of the flap occurred in 21 patients. Long-lasting
nasal obstruction could be observed in 68 patients and OSAS
in 5 cases. We had no mortality. The flap did not exert
significant effect on the maxillofacial growth. In order to
decrease the number of complications, careful preoperative
examination, proper experience of the surgeon, adequate
narcosis, well-chosen operative technique, and appropriate
postoperative care are essential.
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